Elderly Health Journal 2016; 2(2): 67-72.
Shahid Sadoughi University of Medical Sciences, Yazd, Iran
Journal Website : http://ehj.ssu.ac.ir
Original Article
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The Association between Spiritual Health and Blood Sugar Control in Elderly
Patients with Type 2 Diabetes
Moradali Zareipour1, Zahra Khazir1, Rohollah Valizadeh2, Hassan Mahmoodi3, Mousa Ghelichi
Ghojogh4*
1.
Department of Health Education and Promotion, School of Public Health, Shahid Sadoughi University of Medical
Sciences, Yazd, Iran
2.
Student Research Committee, School of Public Health, Urmia University of Medical Sciences, Urmia, Iran
3.
Department of Health Education and Promotion, School of Public Health, Tabriz University of Medical Sciences,
Tabriz, Iran
4.
Department of Public Health, School of Medicine, Urmia University of Medical Sciences, Urmia, Iran
ABSTRACT
Article history
Received 19 Jul 2016
Accepted 28 Sep 2016
Introduction: Spirituality is taken deeply into consideration as a part of health because of
its role in the control of chronic diseases and its importance in determination of life purpose
in the elderly. This study aimed to investigate the association between spiritual health and
blood sugar control in elderly patients with type 2 diabetes.
Methods: This cross-sectional study was conducted on 200 elderly patients with type 2
diabetes from 10 rural health centers of Urmia city, north west of Iran. These patients were
selected by cluster random sampling. Data were collected by Spiritual Well-Being Scale of
Paloutzian and Ellison. Glycated hemoglobin (HbA1c) was used to measure blood sugar
control status of diabetic patients. Data were analyzed using descriptive statistics and chisquare test and Pearson correlation coefficient in SPSS software.
Results: The spiritual health score in 43% of the elderly with diabetes was moderate and 57
% had high spiritual health level. There was statistically significant relationship between
spiritual health and gender, age, education, occupation and economic status. The results also
showed that there was no significant correlation between spiritual health and its subdomains
with HbA1c (r = 0.07).
Conclusion: In this study, there was no statistically significant difference between spiritual
health scores in patients with uncontrolled and controlled blood sugar. It is suggested to
conduct case-control study with larger sample size on factors affecting blood sugar control.
Keywords: Spiritual Health, Blood Glucose, Aged, Diabetes Mellitus
Citation: Zareipour M, Khazir Z, Valizadeh R, Mahmoodi H, Ghelichi Ghojogh M. The association between spiritual
health and blood sugar control in elderly patients with type 2 diabetes. Elderly Health Journal. 2016; 2 (2): 67-72.
Introduction
The diabetes epidemic is now one of the main
causes of attenuation and disability and one of the
concerns are exacerbated public health in the world,
based on the current trend, approximately 75% of
cases in the world in 2025 will be identified in
developing countries (1). In addition to the high
incidence of diabetes mellitus in throughout the world
and an increase of prevalence from 4% in 1995 to
4.5% in 2025, serious complications are the causes of
*
special attention of governments to the disease such as
retinopathy, nephropathy, neuropathy, diabetic foot,
non-traumatic amputation, kidney disorders and
atherosclerosis (2). The prevalence of diabetes was
7.7% in Iran in 2005, approximate 2 million people
and is projected to be in case of the continuation of
the current trend , reach nearly to 5.2 million cases in
2025 (3). The prevalence of diabetes is extrapolated to
the Iranian population aged 25–64 years and the
Corresponding Author: Department of Public Health, School of Medicine, Urmia University of Medical Sciences, Urmia, Iran.
Tel: +984432222595, Email address: [email protected]
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Zareipour et al.
prevalence in aged 55–64 years is 16.8% (4).
Considering that the present recovery in diabetic
people is almost impossible, in conclusion the
therapeutic care is the control of disease.
The use of religious beliefs and spirituality is often
considered as a strategy of constructive confrontation
in psychological health improvement of individuals.
The importance of morality and spiritual growth in
human beings, in the past few decades are
increasingly taken psychology and mental health
professionals into consideration that the World Health
Organization in defining the dimensions of human
points physical, mental, social and spiritual
dimensions (5). Spiritual health is the newest
dimension which places beside other dimensions;
physical, mental and social health. Some even believe
that without the spiritual health, other health
dimensions cannot have the desired maximum yield
and it is not possible to reach high quality of life (6).
Spiritual health is one of the fundamental concepts
about how the stress-induced problems and indeed
with the disease that includes two existence and
religious dimensions. Religious health is defined as a
connection and commitment to a particular religious
belief and existence health is defined to reach the
meaning of life and how to achieve perfection (7).
When spiritual health of person goes to the serious
risk, it may be experiencing the feelings of loneliness,
depression and the feeling of not having a meaning in
life. As well as spiritual health plays a vital role in
coping with stress and has positive effect on health
promotion (8). The researchers emphasized that the
increased level of meaning and spirituality in the life
not only overcome conflicts but also increases life
satisfaction (9).
The American Diabetes Association has
emphasized cultural factors may be uniquely effective
on blood sugar control. Spirituality and religion as one
of the prominent and important cultural factors have a
significant role in dealing with the problems and
emotional support (4). Whelan-Gales et al. on a study
on the elderly in 2009 in the United States showed a
reduced amount of spiritual health causes depression.
They suggested that you should have holistic view
about elderly and especially pay attention to their
spiritual health (9). The results of You et al. have
shown that elderly people with strong religious beliefs
have optimal health compared with others. In
addition, elderly people with faith suffering with
certain physical disease had better performance
compared with elderly with weak faith and
experienced better results from treatment (10).
The results of Arcury et al. on elderly patients with
diabetes showed that, there are relationship between
religious activity and mental health, physical health
and mortality, but poor health with levels of religious
activities especially like to pray or use of the media
were not associated (11). The results of Campbell et
al. in 2010 showed that patients with cancer, stroke
and rehabilitation phase after head trauma did not
support the hypothesis, and there was no correlation
between individual religious activity and physical
health (12). In the study of Shahdadi et al. results
Elderly Health Journal 2016; 2(2): 67-72.
showed that spirituality rate of diabetes patients were
high but there was no association between spirituality
and type 2 diabetes (13).
According to the above research that some have
confirmed positive effects of religious health on
physical and mental health, in other cases such effects
are not found. So far, there is no study on the
relationship between blood sugar control and spiritual
health in the elderly, as one of the dimensions of
physical health, in Iran. This study aimed to
investigate the association between spiritual health
and blood sugar control in elderly patients with type 2
diabetes.
Methods
Subjects
In this cross-sectional study, study population was
consisted of diabetic elderly over age 60 referred to
rural health centers of Urmia city, north west of Iran,
in 2016. According to recent studies and estimation of
the average amount of spiritual health of the elderly
(9-14), considering confidence level of 95%, d = 0.6,
z = 1.96 and p = 0.3, required sample size was
determined 200 subjects by Cochran formula. At first
10 of 35 health centers of rural health centers were
selected by random sampling and after informed
consent, diabetic elderly from each center were
included to study according to the population of
diabetic elderly.
The patients excluded if there were history of
mental diseases such as depression or handicap in
their file as well as patients who were not done
HbA1c test in the past month were excluded.
Procedure
At first, the subjects that were randomly selected
for participating in the study through a phone call
were invited to the health center. Objectives of the
study were described to them, and then they were
asked to complete the questionnaires. In case of low
or illiteracy or inability to complete the questionnaire,
interview was applied by an educated staff. Glycated
hemoglobin (HbA1c) of patients was extracted by an
educated staff from the stored files in the center.
HbA1c 6-4% was considered good control, 8-6%
weak control and more than 8% unacceptable control
(15).
Measures
In this study two questionnaires were used;
demographic characteristics and spiritual health
questionnaire. Personal characteristics included age,
education and occupation and spiritual health.
Spiritual health questionnaire is consists of 20
questions about Spiritual Well-Being Scale of
Paloutzian and Ellison (SWBS) (16-17). In this 20item questionnaire for spiritual well-being, there were
10 questions for religious and 10 for existence health.
The score of spiritual health is the sum of these two
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Spiritual Health and Blood Sugar Control in Elderly
subscales that has a range 20 to 120. The range of sixpoint Likert scale was classified from strongly
disagree until completely agree. Each question score
is 1-6.In negative questions, scoring is done in reverse
shape and in the end, the spiritual health classified in
three level, low 20-40, moderate 41-99 and high 100120. This questionnaire was used in the study of
Jadidi in Iran and its validity and reliability was
confirmed (18). In the study of Seyed et al. also the
content validity and reliability of spiritual health
questionnaire was determined and confirmed (19).
Ethical considerations
The objectives of the study were explained to all
participants and all of them accepted to participate and
were assured of the confidentiality of their individual
information as well as the voluntary nature of
participating in the study.
Data analysis
Data was analyzed using the SPSS software and
using the Pearson and Chi-square tests. Significance
level was considered less than 0.05.
Results
The mean age of participants was 70.51 ± 8.7 that
(62.5%) 125 subjects were female. In terms of
education level, most of the patients were illiterate
(71.5%) and housewife (56%). In terms of marital
status, 146 subjects (73%) were married and 50 cases
(25%) were widow and 4 subjects (2%) were living
alone. In terms of the type of diabetes treatment, most
participants (77.5%) took the pill. In terms of taking
smoking, 178 cases (89%) were not smoker. In terms
of the economic status, 132 subjects (66%) were on
average level.
The results of this study showed that the average
score for the spiritual health of the elderly was 95.85
± 14.03 of the total score of 120. In spiritual health
section, 43% of patients had moderate spiritual health
and 57% had high spiritual health and none of the
samples had low spiritual health. The spiritual
dimensions of health indicated that the average score
for religious health (51.28 ± 8.14) was higher than the
average score for physical health (44.57 ± 7.69). The
mean HbA1c of diabetic patients was 7.87 ± 1.9.
About half of the participants had more poorly
controlled blood sugar (47%). (Table 1)
Relationship between demographic variables and
spiritual health was examined using Chi-square. The
results showed that the spiritual health had a
significant relationship with sex, age, education,
occupation, economic status (p < 0.05). But spiritual
health had not significant relationship with marital
status, blood lipids, diabetes complication and body
mass index. (Table 2)
In the present study the weak reverse correlation
between spiritual health and its domain with blood
sugar control was observed so that the diabetic elderly
69
blood sugar decreases, not statistically significant
though, when spiritual health increases proportionally.
(p < 0.05, r = -0.07). (Table 3)
Discussion
This study showed that the majority of diabetic
elderly have high spiritual health (95.85 ± 14.3) and
the rest have moderate score. This point according to
religious and cultural beliefs of rural elderly is
justifiable. In the study of Whelan-Gales et al. (9) the
average score of spiritual health in the elderly with
heart disease in the United States and in the study of
Jadidi et al. (18) the spiritual health of elderly in
nursing home of Tehran's Kahrizak and in the study of
Shahdadi et al. (13) the spiritual health of patients
with diabetes in Ghoochan city were reported from
moderate to high. One possible explanation is that the
elderly mostly tend to religion and spirituality for
seeking power and protection of spiritual force.
The results of this study represents a higher
religious health score compared with existence health
that were compatible with the results of the study of
Jadidi et al. and Khalili et al. in a study of the spiritual
health of elderly (18-20) that maybe the cause of it as
being higher role of religious beliefs in stressful
situations such as disease control. On the other hand,
the result of this study was inconsistent with the study
of Alahbakhshian et al. that represents higher role of
existence health in patients with multiple sclerosis (6).
In justifying the cause, it can be said that individuals
in order to control their stress in chronic diseases, use
different ways related to social and psychological
concerns (existence health) and being compatible with
the environment and their community.
In the present study the spiritual health of male
subjects were greater than females’ that is consistent
with the study of Khalili et al. (20) and Sadrollahi et
al. (21) but is inconsistent with the study of
Kandasamy et al. (22) in India that the spiritual health
of women were greater than men. The spirituality
difference between men and women could be
attributed to cultural and social factors and the kind of
view to spirituality. Because men compared with
women have more opportunity to participate in the
rites and mosques and religious ceremony, it is
expected that the rate of spiritual health and
satisfaction of this health dimension in men be greater
than women.
There was significant relationship between spiritual
health and age so that spiritual health rises with
increasing age and this is consistent with the study of
Saydshohadai et al. (23) and is inconsistent with the
study of Jadidi et al. and Sadrollahi et al. (18, 21) .
Pulling towards spirituality is considered as yield of
increasing age because it is a way by which a person
face with death reality.
The results indicated that with increasing the status
of education in elderly, their spiritual health rises that
is consistent with the results of Seyed Fatemi et al.
(19) and Khalili et al. (20) and is inconsistent with the
study of Jadidi et al. (18) and Saydshohadai et al. (23).
Elderly Health Journal 2016; 2(2): 67-72.
Zareipour et al.
Table 1. The status of spiritual health and glycated hemoglobin in elderly with diabetes
Spiritual health
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Blood Sugar
Control
Moderate(41-99)
High (100-120)
Good control(4-6)
Weak control(6-8)
Unacceptable control (more than 8)
N
%
Mean ± SD
Range
86
114
30
94
76
43
57
15
47
38
95.85 ± 14.03
64-119
7.87 ± 1.9
4-15
Table 2. The relationship between demographic variables and spiritual health in elderly with diabetes
Variable
High
Moderate
p
Sex
Female
Male
61 (48.8)
53 (70.7)
64 (51.2)
22 (29.3)
0.02
Marital status
Single
Married
Dead husband
3 (75)
83 (56.8)
28 (56)
1 (25)
63 (43.2)
22 (44)
0.75
Age
60-70
70-80
More than 80
65 (53.7)
34 (65.4)
19 (70.3)
56 (46.3)
18 (34.6)
8 (29.7)
0.03
Education level
Illiterate
Primary
Diploma and more
71 (49.7)
39 (79.6)
5 (62.5)
72 (50.3)
10 (20.4)
3 (37.5)
< 0.001
Occupation
Farmer/rancher
Housekeeper
Self-employment
Other
44 (78.6)
57 (50.9)
8 (53.3)
5 (29.4)
12 (31.4)
55 (49.1)
7 (46.7)
12 (70.6)
0.001
Triglyceride
Yes
No
41 (51.2)
73 (60.8)
39 (48.8)
47 (39.2)
0.11
Complication of diabetes
Yes
No
13 (52)
101 (57.7)
12 (42.3)
74 (42.3)
0.37
Economic status
Good
Moderate
Weak
22 (68.8)
79 (59.8)
13 (36.1)
10 (20.4)
53 (40.2)
23 (63.9)
0.013
BMI
18.5-24.9
25-29.9
≥ 30
26 (55.3)
47 (61.8)
41 (53.2)
21 (44.7)
29 (38.2)
36 (46.8)
0.54
Table 3. Correlation between spiritual health dimensions and blood sugar in elderly with diabetes
Spiritual health dimensions
Physical health
Religious health
Spiritual health(total)
Some possible reasons are the higher rate of spiritual
health in literate people, more knowledge about the
concepts of the meaning of spiritual health and
employing them in daily life.
Farmers and ranchers have the highest spiritual
health that is consistent with the study of Sadrollahi et
al. (21) that showed employed elderly have high
spiritual health. The main reason for this is the feeling
of being useful and higher life satisfaction.
Elderly Health Journal 2016; 2(2): 67-72.
Blood sugar
p = 0.31
p = 0.35
p = 0.27
r = -0.07
r = -0.06
r = -0.07
There was a significant relationship between
economic status and spiritual health of elderly. The
elderly, who had good economic status, had higher
level of spiritual health. These findings were
consistent with the study of Saydshohadai et al. (23)
and Lynch et al. (24) that showed a significant
relationship between the spiritual health and financial
income situation of elderly.
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Spiritual Health and Blood Sugar Control in Elderly
Finally, to answer the question, weak reverse
correlation observed between spiritual health with
blood sugar control that means although spiritual
health increases, when blood sugar of diabetic elderly
decreases but this is not statistically significant. The
results of the studies of Newlin et al. (14), Shahdadi et
al. (13) and Heidari et al. (25) showed that there was
no significant relationship between HbA1c and
spiritual health and dimensions of religious and
existence health that is consistent with the results of
present study and is inconsistent with the study of
Ramazankhani et al. (26) indicated that there is a
significant relationship between spiritual health and
controlled blood sugar in diabetic patients.
4.
5.
Conclusion
Although in the present study there was no
significant relationship between spiritual health and
blood sugar control but the spiritual health is unique
force that cooperates physical, mental and social
dimension of human. When spiritual health seriously
is compromised, individuals may encounter with
mood disorders, such as loneliness, depression and
loss of meaning in life.
6.
7.
8.
Study limitations
Being cross-study and data collection based on selfreporting are limitations of this study. It is suggested
to conduct case-control and longitudinal studies with
greater sample size associated with the evaluation of
the effective control of blood sugar such as self-care,
mental health status and social support of the patients
and so on.
9.
10.
Conflict of interest
The authors declared that there are no conflicts of
interest in this study.
Acknowledgment
The authors would like to thank all responsible of
health centers of the city of Urmia for suitable
cooperation and especially of the diabetic elderly
participating in the study.
11.
12.
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